Provider Demographics
NPI:1336441765
Name:WAGNER, LAURA (ARNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 COOPER POINT ROAD SW
Mailing Address - Street 2:STE C-4
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502
Mailing Address - Country:US
Mailing Address - Phone:360-515-0342
Mailing Address - Fax:360-338-0502
Practice Address - Street 1:1700 COOPER POINT ROAD SW
Practice Address - Street 2:STE C-4
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502
Practice Address - Country:US
Practice Address - Phone:360-515-0342
Practice Address - Fax:360-338-0502
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60190973363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health